Healthcare Provider Details

I. General information

NPI: 1912474800
Provider Name (Legal Business Name): PHG UNION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E SHORT HILLSBORO ST
EL DORADO AR
71730-6458
US

IV. Provider business mailing address

1700 E SHORT HILLSBORO ST
EL DORADO AR
71730-6458
US

V. Phone/Fax

Practice location:
  • Phone: 870-862-5124
  • Fax: 870-881-8053
Mailing address:
  • Phone: 870-862-5124
  • Fax: 870-881-8053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID LEMCKE
Title or Position: MEMBER
Credential:
Phone: 678-808-4071